Suicide prevention: reflections on progress over the past decade

Interest in preventing suicides has increased greatly in recent years. In this Personal View, we consider the general global developments related to suicide prevention that have occurred in the decade since The Lancet Psychiatry was first published in 2014. We then review specific advances during this period, first, in relation to public health initiatives, and second, with regard to clinical developments. Finally, we examine some of the challenges that currently confront individuals and organisations responsible for designing and implementing suicide prevention measures.

Changes in Media Reporting Quality and Suicides Following National Media Engagement on Responsible Reporting of Suicide in Canada: Changements de la Qualité des reportages dans les médias sur les suicides suite à l'engagement des médias nationaux à la déclaration responsable du suicide au Canada

OBJECTIVE

Responsible media reporting is an accepted strategy for preventing suicide. In 2015, suicide prevention experts launched a media engagement initiative aimed at improving suicide-related reporting in Canada; its impact on media reporting quality and suicide deaths is unknown.

METHOD

This pre-post observational study examined changes in reporting characteristics in a random sample of suicide-related articles from major publications in the Greater Toronto Area (GTA) media market. Articles (n = 900) included 450 from the 6-year periods prior to and after the initiative began. We also examined changes in suicide counts in the GTA between these epochs. We used chi-square tests to analyse changes in reporting characteristics and time-series analyses to identify changes in suicide counts. Secondary outcomes focused on guidelines developed by media professionals in Canada and how they may have influenced media reporting quality as well as on the overarching narrative of media articles during the most recent years of available data.

RESULTS

Across-the-board improvement was observed in suicide-related reporting with substantial reductions in many elements of putatively harmful content and substantial increases in all aspects of putatively protective content. However, overarching article narratives remained potentially harmful with 55.2% of articles telling the story of someone's death and 20.8% presenting an other negative message. Only 3.6% of articles told a story of survival. After controlling for potential confounders, a nonsignificant numeric decrease in suicide counts was identified after initiative implementation (ω = -5.41, SE  =  3.43, t  =  1.58, p  =  0.12).

CONCLUSIONS

We found evidence that a strategy to engage media in Canada changed the content of reporting, but there was only a nonsignificant trend towards fewer suicides. A more fundamental change in media narratives to focus on survival rather than death appears warranted.

Nigerian newspapers coverage of suicide: Assessment of adherence to WHO suicide reporting guidelines

Context

Despite an increase in research evidence on media compliance with suicide reporting guidelines globally, evidence from Nigeria seems to be relatively limited.

Aim

This study assessed the prevalence of World Health Organization (WHO) helpful/harmful suicide reporting cues in suicide stories reported by Nigerian newspapers in 2021.

Setting and Design

The setting is the entire Nigeria and the design is descriptive.

Method

Quantitative content analysis method was adopted and 205 online suicide-related stories from news portals of 10 purposefully selected newspapers were analyzed. The newspapers selected were among the top 20 in Nigeria and had higher circulation/coverage and considerable online presence. Evaluation framework was designed following moderated WHO guidelines.

Statistical Analysis Used

Descriptive statistics (frequencies and percentages) were used for the analysis.

Results

The study suggested high prevalence of harmful reporting and near absence of helpful suicide reporting cues among Nigerian newspapers. Majority of the stories, 95.6% mentioned suicide in the headline; 79.5% provided details on the suicide methods employed; 66.3% offered mono-causal explanation to suicide; and 59% featured images of suicide victims and/or suicide-related graphics. Helpful reporting cues were almost nonexistence as only less than 4% of the stories traced warning signs, reported mental health experts/professionals' opinions, featured research findings/population level statistics, and provided details on the identity/contact of suicide prevention programs/support services.

Conclusion

Prevalence of harmful suicide-reporting practice among Nigerian Newspaper presented a gloomy future for suicide prevention in the country. There be training and motivation programs for health/crime reporters/editors on responsive media coverage of suicide following (a domesticated) WHO guidelines.

Media coverage and speculation about the impact of the COVID-19 pandemic on suicide: a content analysis of UK news

OBJECTIVES

Since the start of the COVID-19 pandemic, there has been much concern and speculation about rises in suicide rates, despite evidence that suicides did not in fact increase in the first year of the pandemic in most countries with real-time suicide data. This public narrative is potentially harmful, as well as misleading, and is likely to be perpetuated by sensational news coverage.

METHOD

Using a bespoke database, we analysed the quality and content of print and online UK news (including opinion pieces) on the impact of COVID-19 on suicidality, based on adherence to international recommendations. χ² tests were conducted to examine variability in relation to key characteristics (eg, type of publication) and to four 'restriction phases' (based on UK government official lockdown measures) over the first 14 months of the pandemic.

RESULTS

We identified 372 stories about COVID-19 and suicidality in online and print news between the first UK lockdown (March 2020) and May 2021 (when restrictions were significantly eased in the UK). Throughout this period, over a third of articles (39.2%) and headlines (41.4%) claimed or predicted a rise in suicide, often attributed to feelings of entrapment and poor mental health (especially among young people) and fueled by expert commentary and speculation. Almost a third of reports were rated as being of negative quality (116, 31.2%), and at least half included no signposting to help and support. However, reporting improved in phases of less stringent COVID-19 restrictions and over time, with later articles and headlines including fewer negative statements and predictions about rises in suicides, and greater reliance on academic evidence.

CONCLUSIONS

As the longer-term consequences of the pandemic develop, and other national and global events unfold, it is increasingly important that the media, and the wider community of experts shaping its narratives, strive for a positive and evidence-informed approach to news coverage of suicide.

News reporting of suicide in nurses: A content analysis study

Media impact on suicide is well-established. Groups at heightened risk of suicide, such as nurses, may be particularly influenced by poor news reporting. This study aimed to examine UK newspaper reporting of suicide of nurses and student nurses, including during the COVID-19 pandemic. Print and online newspaper reports about suicide in nurses (including students) published in the UK between January 2018 and August 2021 were obtained and data extracted for analysis in collaboration with Samaritans' media advisory team. Content and quality of newspaper reports were examined using a content analysis approach. The study was compliant with the STROBE checklist. Nurse or student nurse suicides were reported in 134 articles, including 50 individual suicides. Most articles were acceptable against Samaritans' media guidelines. However, common problems included absence of signposting to support organizations and lack of suicide prevention messages. A minority of articles included methods of suicide within article headlines (18, 13.4%) and sensationalist or romanticizing language (14, 10.7%). Most contained occupation-related content. Many named the individual's specific hospital or university and a substantial proportion included occupation-related images. Working on the frontline was the most reported link between COVID-19 and nurse suicide. While reporting on suicide among nurses and students was largely acceptable, quality of reporting was variable. Occupation was often discussed, and most articles published during COVID-19 linked suicide to the pandemic. The research findings can help shape guidance on reporting of suicide in specific professions and occupations, including nursing, to encourage responsible reporting and reduce inadvertent promotion of suicide.

Social media monitoring of suicidal content and change in trends of Japanese twitter content around the Zama suicide pact slayings

Social media-related suicides remain a serious issue despite efforts to address this problem. On October 31st, 2017, the Zama Suicide Pact Slayings were reported in which a criminal targeted victims who expressed suicidal ideation using social media. We analyzed how communication on Twitter was used concerning suicidal ideation in relation to the slayings. We extracted data from 1,246 Twitter accounts using the hashtag "#I_want_to_die" between October 1st to November 30th, 2017. We performed thematic content analysis to identify the characteristics of these Twitter accounts and their tweets. The number and categories of related posts from before and after the slayings were compared. Relevant online communication increased from 159 to 1,037 Twitter accounts after the incident. Before the incident, most accounts had tweets related to suicide, mental health issues, or sought to make connections. After the incident, most tweets from these accounts were related to opinions (especially offensive ones) or non-prevention-oriented advertisements. The results suggest that the number of accounts tweeting suicidal-related themes decreased after the homicides, while the number of accounts posting offensive opinions and non-preventive advertisements increased. This implies that the efficacy of social media-based prevention measures may be undermined by this content.

Have News Reports on Suicide and Attempted Suicide During the COVID-19 Pandemic Adhered to Guidance on Safer Reporting?

Background: Associations between sensational news coverage of suicide and increases in suicidal behavior have been well documented. Amid growing concern over the impact of the COVID-19 pandemic on suicide rates, it is especially important that news coverage adheres to recommended standards. Method: We analyzed the quality and content of print and online UK news reports of possible COVID-19-related suicides and suicide attempts in the first 4 months of the pandemic (N = 285). Results: The majority of reports made explicit links between suicidal behavior and the COVID-19 pandemic in the headline (65.5%), largely based on statements by family, friends, or acquaintances of the deceased (60%). The impact of the pandemic on suicidal behavior was most often attributed to feelings of isolation (27.4%), poor mental health (14.7%), and entrapment due to government-imposed restrictions (14.4%). Although rarely of poor overall quality, reporting was biased toward young people, frontline staff, and relatively unusual suicides and, to varying degrees, failed to meet recommended standards (e.g., 41.1% did not signpost readers to sources of support). Limitations: This analysis cannot account for the impact of reporting on suicide. Conclusion: Careful attention must be paid to the quality and content of reports, especially as longer-term consequences of the pandemic develop.

Content analysis of reports of student suicide deaths in South African print medium newspapers

Purpose

The aim was to assess the quality of newspaper reporting of university student suicides in South Africa, using the World Health Organisation guidelines. Suicide among university students is a growing public health problem. The media has an important role to play in preventing student suicides by adhering to international best practice guidelines on ethical reporting of suicides.

Design/methodology/approach

This study conducted a content analysis of print medium newspaper articles in the 13 most widely read English language South African newspapers from the period of January 2017 to January 2020.

Findings

The initial search yielded a total of 28 news reports, of which 19 met this study’s inclusion criteria and were analysed using content analysis. The quality of reporting showed both potentially harmful and helpful characteristics. Poor adherence to international reporting guidelines were found in the description of method and location of suicide, sensational headlines, publishing photos of the deceased, linking suicide to criminality, simplistic narration of the life events leading to the suicide and use of sensational and potentially triggering language. No reports adhered to all reporting guidelines. Findings suggests that there are widespread potentially unhelpful practices in the reporting of student suicides and a need for suicide prevention experts to work with journalists to promote critical reflexivity and ethical reasoning when writing about student suicides.

Research limitations/implications

This study only included news reports published in English in the most widely read newspapers.

Originality/value

To the best of the authors’ knowledge, this is the first study of its kind to systematically examine media reporting on suicide in South Africa.

Bearing witness: A grounded theory of the experiences of staff at two United Kingdom Higher Education Institutions following a student death by suicide

Wider networks of people are affected by a suicide death than originally thought, including those whose job-role brings them into contact with a death by suicide of another person. The impact of student suicide within United Kingdom (UK) Higher Education Institutions (HEIs) is unexplored and the experiences of staff members remain unknown. It is not known whether staff members have specific postvention needs following a student death by suicide. Any postvention support currently offered to staff members within UK HEIs lacks a context-specific evidence base. This study asked 'How is a student suicide experienced by staff members within a UK HEI and what are the features of that experience?' Staff members from diverse job-roles in two UK HEIs responded to a qualitative survey (n = 19) and participated in semi-structured interviews (n = 10). Data were transcribed and subjected to a constructivist grounded theory analysis. Participants' experiences informed the development of a core category: 'Bearing witness', which encompassed six further categories: 'Responding to a student suicide'; 'Experiencing a student suicide'; 'Needs and fears'; 'Experiences of support'; 'Human stories'; and 'Cultural stories'. The resulting grounded theory demonstrates how participants' perceptions of impact are informed by their experiences of undertaking tasks following a student suicide within the community of their HEI. Processes of constructing perceptions of closeness to the student who died are evident amongst participants who did not know the student prior to their death. Tailored postvention support is required to respond to the range and complexity of HEI staff needs following a student death by suicide.

Online media reporting of suicidal behaviour in Ghana: Analysis of adherence to the WHO guidelines

BACKGROUND

Irresponsible media reporting of suicide is a potential risk for copycat suicide. There is a paucity of studies from sub-Saharan Africa on the quality of media reporting of suicide.

OBJECTIVES

We assessed the compliance of Ghanaian online media outlets with the World Health Organization (WHO) guidelines for media reporting of suicide.

METHODS

We searched 10 local media outlets with strong online presence in Ghana, to identify suicide-related news reports from 2000 through 2019. We applied summative content analysis and chi-square (χ2) test to the data.

RESULTS

We included 288 news reports, of which 261 (90.6%) were completed suicides, 7 (2.4%) were attempted suicides and 20 (6.9%) were homicide suicides. Most of the news reports failed to comply with the WHO guidelines: 92.7% mentioned the specific method of the suicide act, 82.6% included 'suicide' in the headline and 55.6% included photos of the victims. The χ2 tests indicated that privately owned media outlets were more likely than publicly owned to post a photo of the victim, χ2(1) = 17.37, p < .001, and report the incident location in the headline, χ2(1) = 15.00, p < .001. However, generally, there were no statistically significant relationships between the quality of reporting and media outlet ownership. Each of the 288 reports failed to mention any of the potentially helpful features recommended by the WHO guidelines.

CONCLUSION

Regardless of the ownership of the media outlet (whether private or publicly owned), mostly, the online reportage of suicidal behaviour in Ghana deviates sharply from the international recommended best practice by the WHO.

Patterns and motivations for method choices in suicidal thoughts and behaviour: qualitative content analysis of a large online survey

BACKGROUND

Choice of suicide method can strongly influence the outcome of suicidal behaviour, and is an important aspect of the process and planning involved in a suicide attempt. Yet, the reasons why individuals consider, choose or discard particular methods are not well understood.

AIMS

This is the first study to explore method choices among people with a history of suicidal behaviour and individuals who have experienced, but not enacted, suicidal thoughts.

METHOD

Via an online survey, we gathered open-ended data about choice of methods in relation to suicidal thoughts and behaviours, including reasons for and against specific means of harm.

RESULTS

A total of 712 respondents had attempted suicide, and a further 686 experienced suicidal thoughts (but not acted on them). Self-poisoning was the most commonly contemplated and used method of suicide, but most respondents had considered multiple methods. Method choices when contemplating suicide included a broader range of means than those used in actual attempts, and more unusual methods, particularly if perceived to be lethal, 'easy', quick, accessible and/or painless. Methods used in suicide attempts were, above all, described as having been accessible at the time, and were more commonly said to have been chosen impulsively. Key deterrents against the use of specific methods were the presence of and impact on other people, especially loved ones, and fears of injury and survival.

CONCLUSIONS

Exploration of method choices can offer novel insights into the transition from suicidal ideation to behaviour. Results underscore the need for preventative measures to restrict access to means and delay impulsive behaviour.

Exposure to and experience of self-harm and self-harm related content: An exploratory network analysis

Exposure to the self-harm behaviour of others plays a role in individuals' own self-harm thoughts and behaviours, but there has been little consideration of the broader range of mediums through which exposure to self-harm related content may occur. N = 477 participants completed an online study, including questions regarding lifetime history of self-harm thoughts and behaviours and the frequency with which they had been exposed to self-harm via various mediums. Gaussian Markov random field network models were estimated using graphical LASSO and extended Bayesian information criterion. Bootstrapping revealed that exposure mediums with a direct connection to self-harm thoughts and behaviours were the internet (rrp = .34, 95% CI [.26, .42]) and in-passing 'miscellaneous' exposure (rrp = .14, 95% CI [.00, .23]). However, stability of the network centrality was low (expected influence stability = 0.52). The node with the greatest increase in expected influence within the network was miscellaneous "in-passing" exposure. In-passing exposure is an understudied exposure medium. Our results may suggest new types of exposure mediums for future research. Data were cross-sectional, so temporal relationships between exposure and behaviour could not be determined. Low stability of the networks suggests that future similar studies would benefit from larger sample sizes.

Patterns of suicide mortality in England and Wales before and after the suicide of the actor Robin Williams

PURPOSE

There is international evidence supporting an association between sensational reporting of suicide and a subsequent increase in local suicide rates, particularly where reporting the death of a celebrity. We aimed to explore whether the observed increase in suicides in the United States, Canada and Australia in the 5 months following the 2014 suicide of the popular actor Robin Williams was also observed in England and Wales.

METHOD

We used interrupted time-series analysis and a seasonal autoregressive integrated moving averages (SARIMA) model to estimate the expected number of suicides during the 5 months following Williams' death using monthly suicide count data for England and Wales from the UK Office for National Statistics (ONS) 2013-2014.

RESULTS

Compared with the observed 2051 suicide deaths in all age groups from August to December 2014, we estimated that we would have expected 1949 suicides over the same period, representing no statistically significant excess.

CONCLUSIONS

This finding is an outlier among previous studies and contrasts with the approximately 10% increase in suicides found in similar analyses conducted in other high-income English-speaking countries with established media reporting guidelines.

Media guidelines and suicide: A critical review

By providing information on help-seeking resources (HSR), Google's Suicide Prevention Results (SPR) fill a void, because less than 30% of news reports provide such information. This article addresses larger issues on media guidelines and suicide prevention. First, studies on the effects of providing HSR provide little support for a reduction in suicide. Second, research on the effects of other media guidelines often does not report the anticipated reductions in suicide. Third, although research does tend to support an increase in suicide after publicized suicides of celebrities, it does not necessarily happen for all categories of celebrity suicides. Fourth, there has been a lack of integration of (a) research on imitative effects of publicized suicides and (b) content analysis of stories' adherence to guidelines. Fifth, an associated puzzle is that (a) most research findings (64.2%) show no increase in suicide rates after suicide stories, while (b) most content analyses document widespread violations of media guidelines. Apparently, stories often violate media guidelines, but there is often no anticipated increase in suicide deaths. Rigorous research is needed to fully evaluate which media guidelines matter, and to determine the efficacy of Google's SPR program.

A Content Analysis and Comparison of Two Peaks of Newspaper Reporting During a Suicide Cluster to Examine Implications for Imitation, Suggestion, and Prevention

Abstract. Background: During 2007–2008, media attention focused on a cluster of youth suicides in the UK. There were two peaks (P1, P2) in the volume of newspaper reporting of the deaths. The number of possible suicides was greater than expected at the time of the first peak but not at the time of the second. Aims: To explore any differences in the content of the reporting peaks and to consider implications for imitation and prevention. Method: A content analysis of two peaks of newspaper reporting was conducted. Results: There were 204 articles in P1 (December 27, 2007 to February 19, 2008) and 157 in P2 (February 20, 2008 to March 15, 2008). Four main themes were identified: individual stories; possible causes; features of reporting of the cluster; and educating and informing the public. P1 articles more frequently contained: explicit details of method; photographs of the deceased, and contained more characterization of individuals. Limitations: The focus was on print media, future studies should incorporate online and social media content. Conclusion: The findings provide some support for the hypothesis of a process of suggestion initiated by sensationalist reporting in P1. This contributes to the evidence base of the role of the press in suicide imitation and prevention, highlighting the importance of care when reporting suicides.

The experiences of people bereaved by suicide regarding the press reporting of the death: qualitative study

Background

Media guidelines on suicide reporting of suicide have two purposes: to prevent further suicides, and to minimise distress to the bereaved, who are themselves at increased risk of suicide. We aimed to describe the subjective experiences of people bereaved by suicide regarding media reporting of the suicide of their friend or relative.

Methods

We conducted a cross-sectional study of staff and students aged 18–40 at 37 United Kingdom higher educational institutions in 2010 to recruit adults who had experienced bereavement by the suicide of a close contact. We analysed free-text responses to a question probing experiences of the press after the suicide, using thematic analysis to identify key themes.

Results

We analysed responses from 140 eligible respondents, and identified 3 main themes: value placed on respecting the privacy or wishes of the bereaved; respect accorded to the deceased; and the role of the press in promoting suicide prevention messages. Many respondents described negative experiences of the press, with sub-themes capturing distressing experiences relating to perceptions of journalists’ intrusive behaviour, failure to consult appropriately with the bereaved, journalists releasing private information, negatively misrepresenting the deceased, and breaching the anonymity of the deceased or bereaved. We identified considerable variation in people’s views over acceptable levels of detail reported in the press, and in some cases objections were in relation to journalists following media guidelines. These divergent views illustrate the tensions between the twin purposes of media guidelines: to prevent further suicides, and to protect the bereaved.

Conclusions

The findings from our British sample provide journalists with personal perspectives from bereaved relatives on the impact of media intrusion, speculation, and misrepresentation, and an insight into disparate views on the nature of information relatives feel comfortable disclosing. These findings suggest a need for journalists’ training to include exposure to such views, to heighten awareness of potentially distressing effects and the nuances of bereaved people’s preferences. This should aim to encourage journalists to consult with bereaved relatives more sensitively, whilst also remaining mindful of media guidelines on the reporting of suicide.

The Portrayal of Suicidal Behavior in Police Television Series

Fictional suicidal behavior can affect the public as a risk or a protective factor, and it may reflect how suicide is perceived in a society. However, surprisingly little is known of how suicidal behavior is portrayed in television series. The aim of this study was to investigate the characteristics of televised fatal and non-fatal suicidal behavior, preventative interventions, and the portrayal of people bereaved by suicide. All episodes (N = 475) of four Belgian police series were screened against inclusion and exclusion criteria, and 87 episodes with a total of 54 suicides, 13 attempted suicides, 13 suicide threats, and 20 characters bereaved by suicide were included in a quantitative and qualitative analysis. Televised suicidal behavior was primarily motivated by external motives, such as social/relational issues or the death of a significant other, and to a lesser extent, by internal motives, such as mental or physical health related issues. Interventions were likely to prevent suicide. People bereaved by suicide were mostly portrayed as individuals seeking justice. Shame, revenge, and escape were the major qualitative themes associated with suicidal behavior. Two prototypes emerged: a ruthless, "psychopath" type criminal, who kills him/herself before being arrested, and a suicidal individual struggling with devastating life events. The study provided unique insights in how suicidal behavior is televised in Belgian police series. Though some characteristics were portrayed adequately, mental health related issues were overlooked, spectacular suicide methods were overrepresented, and the bereaved characters were mostly unidimensional revengers. Strategies for improving the accuracy of televised suicidal behavior should be studied.

Clustering of suicides in children and adolescents

Suicide is one of the major causes of death in young people, in whom suicide can occur in clusters. In this Review, we have investigated definitions and epidemiology of such clusters, the factors associated with them, mechanisms by which they occur, and means of intervening and preventing them. Clustering of suicidal behaviour is more common in young people (<25 years) than adults. Suicide clusters can occur as a greater number of episodes than expected at a specific location, including in institutions (eg, schools, universities, psychiatric units, and youth offender units). They might also involve linked episodes spread out geographically. Locations exposed to clusters can be at risk for future clusters. Mechanisms involved in clusters include social transmission (particularly via person-to-person transmission and the media), perception that suicidal behaviour is widespread, susceptible young people being likely to socialise with others at risk of suicidal behaviour, and social cohesion contributing to the diffusion of ideas and attitudes. The internet and social media might have particularly important roles in spreading suicidal behaviour. The effect of suicide clusters on communities and institutions is usually profound. Experience of intervening in clusters has resulted in best practice guidance. This guidance includes preparation for occurrence of clusters in both community and institutional settings. Identification of clusters in the community requires real-time monitoring of suicidal behaviour. Effective intervention is more likely if a cluster response group is established than if no such group exists. The response should include bereavement support, provision of help for susceptible individuals, proactive engagement with media interest, and population-based approaches to support and prevention. Social media can provide a powerful means for disseminating information and reaching young people at risk.